Full Name:

Date of Birth : January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19

Married Single

Wife's First Name:

Home Address:

City: State: Ohio Pennsylvania

Phone Number (XXX) XXX-XXXX:

Driver's License #: State (if other than OH):

Employed by:

Address:

City: State: Ohio Pennsylvania

Work Phone (XXX) XXX-XXXX:How Long There: Months Years

Relative:

Address: City, State:

Relationship:

Personal Friend:

Address: City, State:

Phone (XXX) XXX-XXXX:

RYC Member Reference: none Sam Batianis Carl Beduhn Richard M. Bordenkircher Richard Burns Mike Chandell Kevin Cimorelli Francis Degennaro Fred Eichenlaub David Frye Randy Gegen Steve Gegen Mark Hanna Brian Hubbard Jim Hudson Mike Ivankovic Mike Krengulec Ray Legg Manny Massi Larry McCullough David Palmiter Dave Patterson Robert Sims Roy Skinner Bob Sochia Richard Trebilcock Terry Turner Harry Vlahos Brandon Ward Harry Ward Roger Wasson Dave White

Make of Boat:

Boat Model:

Length (in ft): Beam (12' Max): Draft:

Name of Boat:

Need to Make Changes?

I hereby make application for membership in the Riverside Yacht Club, inc. of Ashtabula, Ohio. I do agree to abide by the By-laws and Constitution of said Club.

Your application will be sent via an unsecure e-mail. If you wish, you may click here to print this application and mail it to Riverside Yacht Club, PO Box 112, Ashtabula, OH 44005-0112